What to include on your employer medical restrictions form

The Saskatchewan Workers’ Compensation Board (WCB) is asking employers to include the following notation on the medical restrictions form (if you use one):

If this form is being used for a work injury at the initial visit, please bill WCB code 640.

Please supply your workers with a medical restrictions form. Workers should provide this form to their care provider during their first visit for return-to-work counselling.

This form outlines what the worker can or can’t do at work because of their injury. There are many names that are used to refer to a medical restrictions form. They include:

• Fitness to return-to-work assessment
• Return-to-work template
• Medical absence report
• Physician’s release to return-to-work form
• Medical certificate employee absence-from-work form
• Statement of medical restrictions form
• Functional abilities assessment form
• Medical assessment form
• Health care provider’s assessment for functional abilities

If you have questions, please contact the WCB at 1.800.667.7590.